Early Warning Score (EWS) & Observations

For the deteriorating adult

Junior Doctor Induction Program.
August 2018

Dr Jonathan Aron, Intensive Care Consultant

On behalf of the Deteriorating Adults Group

Excellence in specialist and community healthcare

Overview

 What is EWS?
 Why is it important?
 What is the process?
 What observations and how?
 How do I calculate it?
 What do I do with the EWS?

EWS / St George’s University Hospitals NHS Foundation Trust

 “A physiological point
scoring system that
efficiently identifies and
should trigger an
appropriate response to
patients who present with
or develop acute illness.”
Royal College of Physicians (2012)
National Early Warning Score (NEWS).
Why is it important?
Why is it important?

“Early recognition
and response of
deterioration
improves patient
safety and
outcomes.”
(Resus Council 2015)
There is no formal outreach team
for acute admissions!

You are the eyes, ears, hands and

advocates for your patients
whilst on the ward!
(you will be pleased to know there is a very proactive
intensive care team and a cardiac arrest team)
Why is it Important?

How does
the right
person get to
see the right
medical
personnel at
the right
time?

Presentation title / St George’s University Hospitals NHS Foundation Trust

Risk Stratification

 Risk stratification is a tool for identifying— and

predicting—which patients are at high risk—or likely to
be at high risk—and prioritising the management of their
care in order to prevent worse outcomes

Presentation title / St George’s University Hospitals NHS Foundation Trust

Why is it important?

Identification and safety Appropriate resource

allocation: staff and
location

Appropriate and
Timely Treatment by
Identification of the most appropriate
acutely unwell patient member of staff
requiring urgent attention
Presentation title / St George’s University Hospitals NHS Foundation Trust
A monitoring tool

 Is not a treatment!
 It is only as useful as the person/people using it
 Needs to be:
 Useful (sensitive and specific)
 Used on the correct population
 Used correctly (calculated correctly)
 Interpreted correctly
 Acted upon correctly

Presentation title / St George’s University Hospitals NHS Foundation Trust

The Chart

EWS / St George’s University Hospitals NHS Foundation Trust

The Chart

EWS / St George’s University Hospitals NHS Foundation Trust

The Chart

EWS / St George’s University Hospitals NHS Foundation Trust

Observations

Complete Set!
 Temperature
 Heart Rate
 Blood Pressure (Systolic Scores)
 Respiratory Rate
 Peripheral Oxygen Saturations
 Flow Rate
 AVPU/New Confusion

EWS / St George’s University Hospitals NHS Foundation Trust

Calculating the EWS

 Each physiological Variable Value Score

observation will give
Temp 37.4 0
you a score from 0 – 3
 Add them all together HR 97 1
to give you a score BPS 95 2
from 0 – 21
RR 24 2
Sats 95 1
 Example: FR RA 0
AVPU A 0
Total 6
EWS / St George’s University Hospitals NHS Foundation Trust
 Frequency & Spacing
Frequency Indication
Continuous/quarter- nEWS > 7
hourly
Hourly nEWS 5 – 6 (or 3 in one)
4 Hourly nEWS 1 - 4
12 hourly nEWS 0
Post - op ¼ hourly for one hour (or until sedation has
worn off and the patient is verbally
responsive)
½ hourly for one hour
1 hourly for two hours
4 hourly until the patients’ observation
return to baseline
EWS / St George’s University Hospitals NHS Foundation Trust
 • Record and Report (HCAs)
What next? • Recognise and Escalate (Nurses)
• Attend and treat (Nurses and Doctors)

Medic REVIEW ST4 + REVIEW ICU REVIEW

EWS / St George’s University Hospitals NHS Foundation Trust

Let’s take an example…

14:15 Male Patient

Lead II
98/min

98 %
O2 Sats

98/55 (68) 36.6 oC What is the nEWS

Score?
NIBP Resp rate Temp
(13:45) 18
Are you
worried?

Presentation title / St George’s University Hospitals NHS Foundation Trust

Presentation title / St George’s University Hospitals NHS Foundation Trust
Presentation title / St George’s University Hospitals NHS Foundation Trust
What information is missing?
 A complete NEWS! 14:45 Male Patient

 ABCDE assessment Lead II

98 %
O2 Sats

 Review of observations trend 98/55 (68)

NIBP
36.6 oC

 History and notes review

(13:45) Temp

 Comprehensive examination
 Review of investigations
 Impression
 Plan
 Watch and wait/further investigations
 Do something (and review to see if successful)
 Escalate
Presentation title / St George’s University Hospitals NHS Foundation Trust
12:45 Male Patient
More information...
Lead II
66/min

98 %
O2 Sats

172/95 (78) 36.6 oC

NIBP Resp rate Temp
(12:45) 14
13:45 Male Patient
Lead II
98/min

98 %
O2 Sats

98/55 (62) 36.6 oC

14:45 Male Patient NIBP Resp rate Temp
Lead II (13:45) 18
128/min

94 %
O2 Sats

78/45 (52) 36.6 oC

NIBP Resp rate Temp
(13:45) 40
Presentation title / St George’s University Hospitals NHS Foundation Trust
Presentation title / St George’s University Hospitals NHS Foundation Trust
How to communicate your findings?

 SBAR
 S=Situation (a concise statement of the problem)
 B=Background (pertinent and brief information related to
the situation)
 A=Assessment (analysis and considerations of options —
what you found/think)
 R=Recommendation (action requested/recommended —
what you want)

 A is also for action appropriate to your skill mix and

location!!

 http://www.ihi.org/resources/Pages/Tools/sbartoolkit.aspx
Presentation title / St George’s University Hospitals NHS Foundation Trust
Messages
 nEWS is a vital tool to identify patients who are
deteriorating and unwell
 It is an excellent rapid, inter-professional communication
tool
 Be aware of its limitations!
 It is only one part of the story!
 As the doctor called to review a patient with a high score
remember:
• You are responsible and have ownership of that
individual – go and review in person!
• Remember your training: ABCDE, history, examination,
interpretation, plan!
• Escalate appropriately and early – everyone is very happy to see
patients before they become critically unwell
Presentation title / St George’s University Hospitals NHS Foundation Trust
Any Questions?

?
EWS / St George’s University Hospitals NHS Foundation Trust
Summary

 Record and Report (HCAs)

 Recognise and Escalate (Nurses)
 Review, treat and escalate (Doctors)
 Complete set of data at an appropriate frequency.
 Complete information is required to make good
decisions!
 Document your thought processes
 Call for assistance early!

EWS / St George’s University Hospitals NHS Foundation Trust

References

 Resuscitation Council (2015) Immediate Life Support. 3rd

Ed. London, RCUK.
 Royal College of Physicians (2012) National Early
Warning Score (NEWS). London, RCP.
 St George’s University NHS Foundation Trust (2017)
Adult Observations Policy. Available online: [add link to
intranet]
 http://www.ihi.org/resources/Pages/Tools/sbartoolkit.aspx

EWS / St George’s University Hospitals NHS Foundation Trust